Fresno State Veteran Students,
If you are planning to join the TRIO Student Support Services Veterans (SSSV)
program for the 2015-2016 academic year, we will need the following
documents to determine your eligibility. These documents will need to be
submitted and reviewed prior to the start of the Fall 2015 or Spring 2016 SSSV
orientations.
An applicant must have the following items completed and submitted before
they are assigned an orientation date and time:
* A completed TRIO Student Support Services Veterans’ application. All
information needs to be accurately filled in.
* Personal Statement questions must be answered and submitted along with a
completed application.
* Submit a copy of your DD-214. If you are a Veteran of the National Guard,
who served on active duty in Iraq and/or Afghanistan, you will need to submit
your NGB Form 22.
* If applicable, submit a copy of your VA disability award letter.
* Submit a copy of 2014 tax records or public benefits award letter. If you did
not submit your tax return for 2014, you must complete a self-reporting form.
All required documentations will need to be submitted ASAP to Jennifer
Garzon in order to be considered for Fall 2015 or Spring 2016. You can submit
your completed application with the required supporting documents to
Jennifer via email at jgarzon@csufresno.edu or in person at the TRIO Program
Office located in the Frank W. Thomas Building, Room 111. If you have any
questions, please call Jennifer at 559.278.5725.
Eluterio L. Escamilla
TRiO SSSV Director
Disclosure Statement: Student Support Services is funded through a TRiO Grant from the U.S. Department of Education. For 2015-2016,
$220,000 (100%) total funds.
Division of Student Affairs
Student Support Services Veterans (SSSV)
2015-2016 APPLICATION
5241 N Maple Ave., Thomas Bldg 122, M/S TA 35, Fresno, CA 93740-8027
(559) 278-5725
http://www.csufresno.edu/sss
Date:____________________
GENERAL INFORMATION
1.
Name:
(Last Name)
(First Name)
(Middle)
2.
Social Security # (Required)_______________ Student ID#: __________
3.
Permanent Address:
Apt #:
City:
4.
State:
Zip Code:
Local Address:
Apt #:
City:
State:
Zip Code:
5.
CSUF Email Address: _____________________________@mail.fresnostate.edu
6.
Cell Phone #: (
8.
Birth date:
11.
Are you a US Citizen? Yes  No (If no, please complete #12, check your status, and
) _______________
_/
/
7. Permanent Phone #: (
9.
)
______
Sex:  Male  Female
PROVIDE A COPY OF YOUR I.N.S. CARD.
If yes, please skip to #14.)
12.
 Permanent Resident Registration card#: ________________________________
 Nonresident Alien Registration card#:__________________________________
13.
What is your birthplace? State ______________ Country ________________
14.
PLEASE ANSWER YES OR NO TO EACH OF THE FOLLOWING QUESTIONS:
 First Generation
 Yes  No
Did either of your parents graduate from a four-year college?  Yes  No
 Low Income (Federal guidelines go to: http://www2.ed.gov/about/offices/list/ope/trio/incomelevels.html)  Homeless?
 Disabled:
Do you have a physical or learning disability?  Yes  No
Do you have a Department of Veterans Affairs disability rating?  Yes  No
Are you registered with Services for Students with Disabilities at CSUF:  Yes
 United States Veteran:  Yes
15.
 No
Branch of Military Service: _____________________
Please circle the highest year in school/college completed by your parents or guardian:
Mother: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17+
16.
 No
Father:
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17+
First language spoken: ________________________________
17. Ethnic Identity
(Please enter the code for your group): _______ (# & letter if applicable)
1 = American Indian or Alaska Native
2 = Asian Specify:
a)Chinese ___ b)Japanese ___ c)Korean ___ d)Filipino ___ e)SE Asian ___
f) Hmong ___ g) Cambodian ___ h) Vietnamese ___ i) Thai ___
3 = Black or African-American
4 = Hispanic or Latino Specify:
a) Mexican/American ___ b) Mexican ___ c) Central American___
d) South American ___ d) Cuban ___ e) Puerto Rican ___
f) Other Latino, Spanish origin, Hispanic___
5 = White
6 = Native Hawaiian or other Pacific Islander Specify: a) Hawaiian ___ b) Pacific Islander ___
c) Guam ___ d) Samoan ___ e) Filipino ___
ACADEMICS:
18.
Declared Major: ________________________, or Undeclared:
□ Yes
□ No
19.
How did you hear about the SSSV?(Please check all that apply). Veteran Services Admissions
Outreach Dog Days Financial Aid Veterans Education Program Student Support Services
Disability VA Central CA Health Care System Fresno County Veterans Services Central Valley
Veterans Omega Delta Sigma Student Veterans Organization
Referral Source:____________________________
20.
Please check all that apply on the table below:
Have you applied for or participated in the following programs?(Please check all that apply).
 Educational Opportunity Program (EOP)
 Services to Students with Disabilities (SSD)
 Renaissance Scholars Program (RSP)
 University Migrant Services/CAMP
 MESA Engineering Program (MEP)
 Educational Talent Search TRiO
 Health Careers Opportunity Program (HCOP) Veteran Services
 Upward Bound/ELL Upward Bound TRiO
Veteran Education Program
 Foster Care/Independent Financial Aid Status  Other: _____________________
HIGH SCHOOL and/or TRANSFER INFORMATION: (Please answer all fields)
21.
22.
23.
24.
First semester enrolled at CSUF:  Fall  Spring  Summer Year_________
How many college units have you completed? ____________________
Name of college or universities previously attended: ________________________________
Name of high school attended: _______________________________________________
FINANCIAL INFORMATION:
25.
Did you file a Free Application for Federal Student Aid (FAFSA) for the most recent academic year?
 Yes  No
26.
List your taxable income from the 2014 Year Federal 1040 Tax Return (or the 1040 EZ Form or the
1040 A Form) below:
Self: 2014 Income: _____________ Your spouse: 2014 Income:
__________________
Most recent tax returns are required prior to TRiO selection and will be required in order to attend orientation.
27.
Total size of your household, including yourself and/or other dependents in your family: ____________
NEEDS ASSESSMENT:
28.
What TRIO SSSV assistance do you desire or think you will need to succeed in college?
 Selecting a Major
 Selecting a Career
 Academic Advising
 Financial Aid Advising
 Tutoring
 Writing Papers/Essays
 Graduate School Information
 Computer Lab
 Reading
 Taking Notes
 Taking Tests
 Stress Management
 Managing Time
 Study Groups for Classes
 Dealing with Personal/Family Issues
 Other:
EQUAL OPPORTUNITY:
Thank you for applying to the TRiO Student Support Services Veterans (SSSV) program. The U.S. Department of Education provides TRiO
funding for the SSSV grant. TRIO SSSV applicants will be considered without regard to race, color, religion, national origin, sexual orientation,
marital status or disability.
DECLARATION:
Any incorrect information given on this application will affect your eligibility for services from the TRIO Student Support Services Veterans.
Pursuant to 20 USA 1231a of the U.S. Department of Education, TRIO Student Support Services Veterans has the responsibility to request from
the applicant and/or guardians any supporting documents to determine eligibility into the program. The information is protected by the privacy act
and is kept personal and confidential. No one may see the information unless they work with, or for, TRIO Student Support Services Veterans, or
are specifically authorized to see it. The information is necessary to determine if the applicant is eligible to participate in TRIO Student Support
Services Veterans, and helps the program measure the applicant’s success. I certify that I have read and agree to the conditions outlined in the
statement above. I, the undersigned, declare under penalty of perjury that all the information reported on this application is true, complete and
accurate to the best of my knowledge. I understand that any incorrect information on this application may affect my eligibility to receive services
from the TRIO Student Support Services Veterans program. I hereby authorize any school, college or university to release any academic or
financial aid information from my files that is requested by TRIO Student Support Services Veterans. I hereby grant permission for my image to
be used in relation to TRIO Student Support Services Veterans activities, which could take the form of a photograph, video, and/or be used on
the TRIO Student Support Services Veterans website accessible on the World Wide Web (internet). I understand that only my name and/or
image(s) will be used, and under no circumstances will any other personal or confidential information be published.
Signature:
Date:
Disclosure Statement: Student Support Services is funded through a TRiO Grant from the U.S. Department of Education. For 2015-2016,
$220,000 (100%) total funds.
PERSONAL STATEMENT FALL 2015 OR SPRING 2016
1. Discuss your personal, educational, and professional goals?
2. Describe one or two challenges or obstacles you have had to overcome, how you overcame
them, and what was the outcome(s)?
I hereby certify that the information provided is true to the best of my knowledge.
________________________________________
Print full name and signature
_______________
Date
Disclosure Statement: Student Support Services is funded through a TRiO Grant from the U.S. Department of Education. For 2015-2016,
$220,000 (100%) total funds.